Inaccurate MDS Coding for Nutrition and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of swallowing/nutritional status and hospitalization. For one resident, who had a percutaneous endoscopic gastrostomy (PEG) feeding tube in place and was receiving regular water flushes via the tube, the quarterly MDS assessment did not reflect the presence or use of the feeding tube or the administration of fluids through it. The Dietary Manager, responsible for coding the Swallowing/Nutrition section, was unaware that the resident still had a PEG tube at the time of assessment. Both the Director of Nursing and the Administrator confirmed that the MDS should have accurately documented the resident's feeding tube status. In another case, a resident's Discharge MDS assessment was incorrectly coded as a discharge to a short-term general hospital, when in fact the resident was discharged home. The error was acknowledged by the MDS nurse, who stated it was unintentional. The Director of Nursing and the Administrator both confirmed that the discharge location was home, not a hospital, and that the MDS assessment should have reflected this.